Chronic kidney disease has emerged as a strong cardiovascular risk factor, and in many current guidelines, it is already considered as a coronary heart disease (CHD) equivalent. Routinely, creatinine has been used as the main marker of renal function, but recently, cystatin C emerged as a more promising marker. The aim of this study was to assess the comparative cardiovascular and mortality risk of chronic kidney disease (CKD) using cystatin C-based and creatinine-based equations of the estimated glomerular filtration rate (eGFR) in participants of population-based and disease cohorts.n = 76,954) from 6 European countries and 3 cardiovascular disease (CVD) cohorts (n = 4982) from Germany. Cox proportional hazards models were used to assess hazard ratios (HRs) for the various CKD definitions with adverse outcomes and mortality after adjustment for the Systematic COronary Risk Evaluation (SCORE) variables and study center. Main outcome measures were cardiovascular diseases, cardiovascular death, and all-cause mortality.The present study has been conducted within the BiomarCaRE project, with harmonized data from 20 population-based cohorts  with creatinine-based CKD and it was 2.14 (95% CI 1.90 to 2.40) based on cystatin-based CKD compared to participants without CKD. In general, the HRs were higher for cystatin C-based CKD compared to creatinine-based CKD, for all three outcomes and risk increased clearly below the conventional threshold for CKD, also in older adults. Net reclassification indices were larger for a cystatin-C based CKD definition. Differences in HRs (between the two CKD measures) in the disease cohorts were less pronounced than in the population-based cohorts.CKD is an important risk factor for subsequent CVD events and total mortality. However, point estimates of creatinine- and cystatin C-based CKD differed considerably between low- and high-risk populations. Especially in low-risk settings, the use of cystatin C-based CKD may result in more accurate risk estimates and have better prognostic value. Chronic kidney disease (CKD) represents a global public health problem and affects a large proportion of the adult population worldwide , 2. CKD Also, subclinical CKD has been associated with a large burden of disease and mortality . This fiThe aim of the study was to assess the prevalence of CKD using creatinine (Cr)- and cystatin C (cysC)-based eGFR equations and their comparative risks for cardiovascular and mortality in participants of cohorts of the MORGAM/BiomarCaRE consortium representing the general population and cohorts with manifest CVD. We also compared the strength of the associations and prognostic values between population-based general and disease cohorts and in specific subgroups .The present study has been conducted within the MORGAM/BiomarCaRE projects, described in detail previously , 11, witIn the population-based cohorts of the MORGAM/BiomarCaRE study, creatinine was measured with the kinetic alkaline picrate Jaffe method with the isotope dilution mass spectrometry (IDMS) traceable (NIST SRM 967) Abbott Architect Assay CREATININE on the Architect c8000. Cystatin C was measured with the immunoassay cystatin C on an Abbott Diagnostics ARCHITECT. All analyses were done at the BiomarCaRE central laboratory at Mainz and after the move in the Medical University Center Hamburg-Eppendorf in Hamburg. The intra- and inter-assay coefficients of variation (CVs) were measured using samples of medium concentrations . The intra-assay CVs for creatinine ranged from 0.09 to 5.2% and for cystatin C from 0.78 to 4.0%, respectively. The inter-assay CV for creatinine ranged from 2.3 to 8.1% and for cystatin C from 1.8 to 12.5% for the measurements in the population-based cohorts. In the disease cohorts, creatinine was measured locally immediately by standardized routine methods in the respective laboratories of the participating centers.https://www.thl.fi/publications/monica/tchol/tcholqa.htm). C-reactive protein was measured on an Abbott Architect c8000 system and the CRP Vario immunoassay ). N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on an ELECSYS 2010 or a Cobas e411 using an electrochemiluminescence immunoassay  ).In addition, total cholesterol was measured locally by routine methods and subject to a central quality control in the general population cohorts (details under Kidney function was assessed by means of eGFR based on the latest equations from the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and included creatinine and cystatin C .eGFRcrea according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPIcrea) equation [k, 1)a × max −1.209 × (0.993)age ×  × (1.159 if black) where k is 0.7 for females and 0.9 for males, a is − 0.329 for females and − 0.411 for males, min indicates the minimum of Cr/k or 1, and max indicates the maximum of Cr/k or 1.equation : eGFR = Cystatin C-based eGFR according to CKD-EPI collaboration [cysC) = 127.7 × (cysC)−1.17 × age−0.13 ×  × (1.06 if black).boration : eGFR  cardiovascular mortality  and (2) cardiovascular disease which was defined in the population-based studies as the first fatal or non-fatal coronary heart disease event or cerebral infarction. The coronary event included acute definite or possible myocardial infarction or coronary death, unstable angina pectoris, cardiac revascularization, or unclassifiable death. Definition of CVD disease outcomes was based on data harmonized in the MORGAM project. For population-based cohorts, participants with prevalent CVD at baseline were excluded from this outcome analysis (note that these participants are still included in the supplementary tables). For the disease cohorts, subsequent CVD was defined as CVD as the main cause of death and non-fatal stroke or myocardial infarction. (3) Total mortality as an endpoint was defined as death due to any cause during the follow-up time. More details of the event classification are provided elsewhere , 32 and  cardiovaThe study populations were described with respect to baseline sociodemographic and medical characteristics. The prevalence of CKD was calculated and displayed across specific age categories. Cox proportional hazards models were used to assess hazard ratios (HRs) for the various CKD definitions with adverse cardiovascular outcomes and mortality after adjustment for the SCORE variables  , 34 and A total of 20 population-based cohorts with 75,367 participants  and with an average follow-up between 2.82 and 23.47 years were included in the study. In addition, three disease cohorts with 4982 patients with manifest CVD  and an average follow-up time between 0.47 and 9.37 years, respectively, were available within the MORGAM/BiomarCaRE consortium for this analysis  based on CKD-EPIcysC after adjustment for covariates. In general, the HRs were higher for cystatin C-based eGFR compared to creatinine-based eGFR for all three outcomes, especially evident for total mortality. Mainly, the NRIne was always larger for CKD-EPIcysC for all three outcomes. It was notably high for the age strata ≥ 65 years for cardiovascular mortality and total mortality  and highest for the stratum diabetes for total mortality (NRIne 9.4%).Figure crea and 3.20 (95% CI 2.04 to 5.01) based on CKD-EPIcysC after adjustment for covariates. Especially for mortality, HRs were more often higher for CKD-EPIcrea. For both CKD variables in disease cohorts, NRIne was highest in the strata female sex, but the patterns were less clear than those in the population-based cohorts.Figure Details of reclassification in both types of cohorts are shown in Additional file 2, even in the age strata 65+ years, pointing to the validity of the current threshold for CKD stage 3+. Additional file Figure 2) seems valid also for participants aged 65 years and older, although the increase in the estimated risk was less steep compared to the younger participants. Notably, higher eGFR-creatinine (≥ 90 mL/min/1.73 m2) was associated with higher hazard ratio of adverse events, while higher eGFR-cysC was not. Compared to a creatinine-based definition of CKD, the cystatin C-based definition of CKD seemed to have a higher specificity, a measure especially important in populations with low prevalence of CKD and therefore resulted in many fewer false positives.This large cohort study conducted within the framework of the MORGAM/BiomarCaRE consortium clearly demonstrated that CKD is an important risk factor for subsequent CVD events and total mortality, both in low- as well as high-risk populations. However, especially in the (low-risk) population-based cohorts, it was evident that analysis of the creatinine- and cystatin C-based eGFRs and their consequences differed considerably. Cystatin C-defined CKD showed a higher prevalence especially in older adults, and cystatin C-based eGFR was associated with higher CVD risk estimates. It seemed also to be associated with better risk classification, especially evident for mortality in older adults. Notably, this difference was not obvious in the relatively older, high-risk disease cohorts. Furthermore, we found evidence that the conventional threshold of CKD  based on creatinine and cystatin C in the population based cohorts. Figure S2. Distribution of the estimated glomerular filtration rate (eGFR) based on creatinine and cystatin C in the disease cohorts. Table S4. Association of CKD with various endpoints (HR and 95% CI) including area-under the curve (AUC with 95% CI) and net-reclassification index (NRI with 95% CI) in population-based cohorts. Table S5. Association of CKD with various endpoints (HR and 95% CI) including area-under the curve (AUC with 95% CI) and net-reclassification index (NRI with 95% CI) in disease cohorts. Table S6. Agreement of reclassification by the CKD-EPIcysC based definition compared to CKD-EPIcrea based definition in the population-based cohorts (Panel A) and in the disease cohorts (Panel B). Figure S7. Spline regression representing creatinine (left side) and cystatin C (right side) based eGFR associated with hazard ratio’s (HR) for mortality after adjustment for SCORE-variables and study center for all and after stratification for age in the disease cohorts. Box S1. Further Description of Study Cohorts.


For novel cancer treatments, effectiveness in clinical practice is not always aligned with clinical efficacy results. As such it is important to understand a treatment’s real-world effectiveness. We examined real-world population-based comparative effectiveness of second-line ipilimumab versus non-ipilimumab treatments (chemotherapy or targeted treatments).We used a cohort of melanoma patients receiving systemic treatment for advanced disease since April 2005 from Ontario, Canada. Patients were identified from provincial drug databases and the Ontario Cancer Registry who received second-line ipilimumab from 2012 to 2015 (treated) or second-line non-ipilimumab treatment prior to 2012 . Historical controls were chosen, to permit the most direct comparison to pivotal trial findings. The cohort was linked to administrative databases to identify baseline characteristics and outcomes. Kaplan-Meier curves and multivariable Cox regression models were used to assess overall survival (OS). Observed potential confounders were adjusted for using inverse probability of treatment weighting (IPTW).p < 0.0001).We identified 329 patients with metastatic melanoma (MM) who had received second-line treatments . Patients receiving second-line ipilimumab were older (61.7 years vs 55.2 years) compared to historical controls. Median OS were 6.9 (95% CI: 5.4–8.3) and 4.95 (4.3–6.0) months for ipilimumab and controls, respectively. The crude 1-year, 2-year, and 3-year OS probabilities were 34.3% (27–41%), 20.6% (15–27%), and 15.2% (9.6–21%) for ipilimumab and 17.1% (11–23%), 7.1% (2.9–11%), and 4.7% (1.2–8.2%) for controls. Ipilimumab was associated with improved OS (IPTW HR = 0.62; 95% CI: 0.49–0.78; This real-world analysis suggests second-line ipilimumab is associated with an improvement in OS for MM patients in routine practice. The treatment effects of novel cancer therapies adopted into clinical practice (effectiveness) do not always align with clinical trial outcomes (efficacy) . In partIpilimumab, an anti-cytotoxic T-cell lympohocyte-4 monoclonal antibody, was the first immune checkpoint inhibitor therapy to show significant survival benefits in patients with unresectable or metastatic melanoma (MM) . Prior tIn the pivotal trial for ipilimumab, Hodi et al. observed survival benefits (hazard ratio (HR) = 0.66; 95% CI: 0.51–0.87) for patients receiving ipilimumab  = 10.1 months) compared to those receiving glycoprotein 100 peptide vaccine alone (median OS 6.4 months) . PatientTo date, only one published study has examined the real-world comparative effectiveness of second-line ipilimumab compared to standard chemotherapy. This study, conducted in Poland, found similar survival benefit as the trial (adjusted HR = 0.65), but observed differences in median OS from the clinical trial experience, including attenuated median OS and less evident survival tail plateau compared to that observed in the trial , 5. AddiUsing population-based data from the Canadian province of Ontario, we set out to quantify the real-world effectiveness of second-line ipilimumab in routine practice, as compared to efficacy observed in pivotal trials.We conducted a population-based comparative retrospective cohort study of individuals treated for MM with second-line ipilimumab, chemotherapy, or targeted therapy between 2012 and 2015 in Ontario. Ontario is the largest province in Canada with a population of approximately 14 million people . For patPatients diagnosed with melanoma  who started first-line systemic treatment for advanced melanoma on or after April 1, 2005 were identified from the Activity Level Reporting (ALR) systemic treatment database maintained by the provincial cancer agency, Cancer Care Ontario. The ALR database consists of population-wide systemic treatment records for cancer patients in Ontario. Patients who received first-line treatment with palliative intent were considered for inclusion, defined as the first non-interferon systemic therapy received by the patient. Since a treatment regimen might consist of multiple drugs provided on different days, a line of treatment was defined as consisting of all chemotherapy drugs given to a patient within four days of the start of treatment. The line of treatment was deemed to continue as long as the patient continued to receive at least one of the drugs. The data sources used to identify treatment regimens are presented in Additional file Patients were included in the study if they started a second line of treatment prior to September 13, 2012  or if they started a second line of treatment with ipilimumab between September 13, 2012 and March 31, 2015 (treated). Historical controls were chosen, to permit the most direct comparison to pivotal trial findings. Patients were excluded if they were younger than 18 at the time of their melanoma diagnosis, had been diagnosed with another prior cancer, received ipilimumab as part of their first-line treatment or received experimental treatment/clinical trial agents as part of their 2nd line of treatment. Potential treated patients were excluded if they received ipilimumab in combination with another treatment  System, Version 10) which were based on diagnoses obtained from hospital discharge records and physician claims records in the 2 years prior to the index date, excluding cancer diagnoses . StatistFor patient and treatment characteristics, mean and standard deviation or median and interquartile range were reported for continuous variables, and frequencies and percentages were calculated for categorical variables. Baseline characteristics of the ipilimumab-treated and control patients were compared using chi-square tests for binary covariates, Kruskal-Wallis tests for categorical variables, t-tests for normally distributed continuous variables, and Wilcoxon rank sum tests for skewed numerical variables.To adjust for differences between groups, propensity scores were calculated using logistic regression, and were used to calculate inverse probability of treatment weights (IPTW) . BaselinOverall survival was assessed using Kaplan-Meier method and log-rank test was performed to assess the difference between groups. Time to death between groups was also compared using a Cox proportional hazards model, weighting patients in each group by their IPTWs. Due to the use of IPTWs, the resulting hazard ratios estimate the average treatment effect, an estimate of the treatment effect if ipilimumab rather than the historical treatments were used as second line treatment in the population of melanoma patients who are similar to those included in this study. Sensitivity analyses were performed, incorporating third-line treatment (if any) into the survival analyses by i) adjusting for the use of third-line treatment as a time-varying confounder; ii) adjusting third-line checkpoint inhibitors treatment as a time-varying confounder; iii) censoring patients at the time of initiating third-line treatment; and iv) excluding patients who received third-line treatment.p-values < 0.05 were considered to be statistically significant. SAS version 9.4  was used for the analyses.Two-sided A total of 728 patients received a second-line treatment for MM between September 13th, 2008 and March 31st, 2015. Of these identified patients, 329 patients met eligibility criteria and were included  (Table The median time from diagnosis to initiating second-line treatment was 18 months (95%CI: 8.4–38.5 months) for second-line ipilimumab patients and 32.5 months (95% CI: 11.9–57.5 months) for historical controls , and time from end of first-line treatment to start of second-line treatment.Approximately half (49.2%) of the patients receiving second-line ipilimumab completed all four planned doses of ipilimumab; the remaining 14.8% had one dose, 19.6% had 2 doses, and 13.2% had 3 doses. Amongst the historical controls, 127 patients received chemotherapy (e.g. dacarbazine and temozolomide) and other treatment (e.g. tyrosine kinase inhibitors), while 13 patients received BRAF/MEK . Amongst the study cohort of patients receiving second-line treatments, 38 (27.1%) historical controls and 64 (35.5%) ipilimumab patients proceeded to receive at least one third-line treatment. Of those patients who received third-line treatments, 27 (71%) historical controls and 51 (76.1%) ipilimumab patients received immunotherapy, while the remaining patients received chemotherapy or other treatments. Amongst the historical controls, the third-line immunotherapy received were mainly ipilimumab whereas the immunotherapy received by the cases were either nivolumab or pembrolizumab.p-value < 0.0001)  in second-line ipilimumab patients and 71.2 months (95% CI: 70.3–116.5 months) in historical controls . Among those patients who received second line ipilimumab and started on third line treatment, the choice of treatment was not significantly associated with survival .Sensitivity analyses were conducted to explore the effect of third line treatment on the association between second-line ipilimumab and OS . The estimated treatment effect was robust under different methods to adjust for the effect of subsequent treatment (HR range = 0.63–0.67). Moreover, despite more older patients receiving second-line ipilimumab (mean age: 61.7 years) compared to chemotherapy or targeted treatment (mean age: 55.2 years) in the real-world, the observed relative treatment effect was still consistent with those reported in the pivotal trial  [In this study, the hazard ratio for overall survival  was similar to the pivotal trial (HR = 0.66). The survival curve also plateaued around two to three years, similar to the pivotal trial. In contrast, the relative estimate of survival benefit, median OS, was shorter in the real-world compared to the pivotal trial for both the ipilimumab patients and the control patients. In particular, the real-world median OS was 2.9 months shorter  in the ipilimumab group and 1.5 months shorter in the control group , compared to clinical trial outcomes. As such, the magnitude of benefit for OS observed in the trial was approximately 3.7 months whereas the real-world effectiveness was 2.3 months. In our real-world setting, less ipilimumab patients were alive at 2-years  and 3-years  [In the population-based study conducted by Polkowska et al., which also compared second-line ipilimumab to second-line chemotherapy, the OS and HR of second-line ipilimumab was similar to our study and the trial. While the median OS were similar between the controls in both studies, patients receiving second-line ipilimumab in our study  had a slightly higher median OS than those patients in Poland , though the confidence intervals were overlapping between the two studies. Additionally, difference in median OS may also be affected by the difference in access to treatments. The authors mentioned that immunotherapies are only available for second and subsequent lines of treatment. While first-line immunotherapies were not publicly funded in Ontario at the time of our cohorts, around 5% of patients in each group had received non-ipilimumab immunotherapies from clinical trials or private payers. Furthermore, the third-line treatment availability may also differ between the two studies. In our study, controls were more likely to receive third-line ipilimumab while treated were more likely to receive third-line nivolumab or pembrolizumab. Despite the differences, both observed median OS for second-line ipilimumab was within the range observed in some of the single-arm studies, which ranged between 6.4 to 8.8 months –14.Our study has a number of notable strengths. We had an extensive collection of linked data, providing detailed information on patient characteristics and treatments for an entire population. Thus, we were able to adjust for many more potential confounders using propensity score methods in contrast to other population-based studies. These variables include rurality, socioeconomic status, previous resection, comorbidity status, and time from diagnosis to initiating second-line treatment. Additionally, we also used different sensitivity analyses to explore the effect of subsequent third-line treatment given that real-world data are non-randomized and that subsequent therapies can be a potential source of confounding. The survival benefit of second-line ipilimumab persisted after these adjustments.Our study has several limitations. First, inherent to observational studies, our estimates may have been affected by residual confounding from unbalanced or unmeasured variables such as performance status, lactate dehydrogenase, and body mass index. Our analysis did not adjust for performance status, though we were able to control for differences in comorbidity, which could affect functional status. Additionally, given this is a pre-funding vs post-funding comparison, it is unlikely that the distribution of performance status of the population would change significantly. Data on lactate dehydrogenase (LDH) was also not available, though notably in the pivotal trial by Hodi et al., there was no significant difference in ipilimumab treatment effect based on LDH , and it In addition to validating the efficacy observed in clinical trials, our study also informs policy decisions in Ontario. While ipilimumab was the first immunotherapy to enter the treatment landscape, other immunotherapies, PD1 inhibitors pembrolizumab and nivolumab, have become available in both first-line and second-line setting in Ontario, along with nivolumab in combination with ipilumumab –19. DespOverall, our findings illustrate the real-world comparative effectiveness of second-line ipilimumab, which was associated with improved survival in patients with MM compared to historical controls, and with HRs similar to those observed in the pivotal trial and other population-based studies. While the relative treatment effect was similar to the pivotal trial, the median overall survival absolute treatment effect observed among real-world patients treated with ipilimumab was smaller and similar to that observed in the other population-based studies.Additional file 1: Appendix: Figure 1: Funding timeline of metastatic melanoma treatments in Ontario. Table 1: Summary of administrative databases.


Previous studies showed that recovered coronavirus disease 2019 (COVID-19) patients can have a subsequent positive polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after they are discharged from the hospital. Understanding the epidemiological characteristics of recovered COVID-19 patients who have a re-positive test is vital for preventing a second wave of COVID-19.This retrospective study analyzed the epidemiological and clinical features of 20,280 COVID-19 patients from multiple centers in Wuhan who had a positive PCR test between December 31, 2019, and August 4, 2020. The RT-PCR test results for 4079 individuals who had close contact with the re-positive cases were also obtained.In total, 2466 (12.16%) of the 20,280 patients had a re-positive SARS-CoV-2 PCR test after they were discharged from the hospital, and 4079 individuals had close contact with members of this patient group. All of these 4079 individuals had a negative SARS-CoV-2 PCR test.This retrospective study in Wuhan analyzed the basic characteristics of recovered COVID-19 patients with re-positive PCR test and found that these cases may not be infectious.The online version contains supplementary material available at 10.1186/s12916-021-01954-1. Re-positive cases: The individuals who recovered from previously confirmed COVID-19 diseases and had a positive test againHospital stay: Time interval of a patient being hospitalizedClose contact: The individuals living in the same houses with the patientsThe ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has caused more than 108 million cases of coronavirus disease 2019 (COVID-19) illness, and over 2.4 million people globally have died from this disease as of February 2021  where reThe COVID-19 outbreak was first reported in Wuhan  and lastCOVID-19 diagnosis and illness severity was defined in accordance with the Chinese management guidelines for COVID-19 published by the National Health Commission of the People’s Republic of China. All first diagnoses of COVID-19 and all re-positive cases were confirmed by a reverse transcriptase-polymerase chain reaction (RT-PCR) test of nasopharyngeal swab or pharynx swab samples. The samples were collected and tested for SARS-CoV-2 in accordance with the WHO guidelines. The kits used are listed in Supplementary Table The discharge criteria of the recovered patients included the following: a normal body temperature for more than 3 days, obviously improved respiratory symptoms, pulmonary imaging showing obvious absorption of inflammation, and two consecutive negative SARS-CoV-2 PCR tests taken at least 24 h apart. Those who met the above criteria could be discharged. After hospital discharge, the patients continued to be in isolation for 14 days at a rehabilitation center, with health monitoring. They wore a mask and lived in a private room with good ventilation. Although the patients had contacts with the staff at the rehabilitation center, the contact was limited, and the staff wore personal protective equipment . The patients were followed up via regular hospital visits every 2 weeks. The patients were tested again 1 month after hospital discharge, with retests every month thereafter. Testing was organized by the local community. If the patient was positive again, he/she was transferred to the hospital or the isolation center. The patient was tested again on the 3rd–5th day after transfer and on the 11th–13th day. Individuals who had close contact with the patient were quarantined in the isolation center and were tested on the 1st–2nd day after entering quarantine and again on the 10th–14th day. Close contacts were defined as individuals living in the same houses as the patients.The sampler gently holds the person’s head with one hand, with the swab in the other, and slowly inserts the swab via the nostril so that it is deep, along the bottom of the lower nasal canal. Because the nasal canal is curved, the swab should not be forced so as to avoid traumatic bleeding. When the tip of the swab reaches the posterior wall of the nasopharyngeal cavity, it is gently rotated once (pause for a moment in case of reflex cough). It is then slowly removed, and the swab tip is dipped into a tube containing 2–3 ml of virus preservation solution . The swab stem is then discarded and the tube cap is tightened.The sampled person first gargles with normal saline. The sampler then immerses the swabs in sterile saline  and holds the person’s head up slightly. With one’s mouth wide open, making a sound “ah” to expose the lateral pharyngeal tonsils, the sampler inserts the swabs, wipes it across the tongue roots, and wipes both sides of the pharyngeal tonsils with pressure at least three times. The sampler then wipes on the upper and lower walls of the pharynxes for at least three times and dips the swab in a tube containing 2–3 ml of storage solution . The swab is then discarded the tube cap is tightened. The pharyngeal swabs can also be placed in the same tube together with the nasopharyngeal swab.The primers and probes used targeted the ORF1ab and N gene regions of SARS-CoV-2. Kit instructions of the manufacturers were followed for nucleic acid extraction, the real-time fluorescence-based RT-PCR reaction system, and the reaction conditions.Negative: no Ct value or Ct value≥ 40. Positive: Ct value < 37. Gray zone: Ct value between 37 and 40; in these cases, a repeat test was recommended. If the Ct value was < 40 and the amplification curve had obvious peaks, the sample was considered to be positive; otherwise, it was considered to be negative. When a commercial kit was used, the instructions provided by the manufacturer prevailed.t-test was used to compare the continuous variables of two groups. The multivariable and univariable logistic regression model was used to determine the associated factors. All statistical analyses were performed using R version 3.4.11 (www.r-project.org). A P value less than 0.05 was considered to indicate statistical significance.In this study, categorical variables are presented as numbers and percentages, and continuous variables are presented as the median . Student’s P < 0.001, Student’s t-test). For cases with a re-positive test, the median hospital stay of the re-positive test was 10.63 days . Among the re-positive cases, the hospital stay for the re-positive test was shorter than that of the original infection (P < 0.001 from Student’s t-test). The median time from hospital discharge to the re-positive test was 11.00 days . Overall, 56.12% of the re-positive cases were women. The median age of the patients was 56.00 years , and more than half of the patients  were aged between 50 and 70 years  (http://tjj.wuhan.gov.cn/tjfw/tjnj/202102/t20210202_1624450.shtml)). Symptoms of the original infection for recovered COVID-19 patients with a re-positive PCR test were 0.24% asymptomatic, 49.67% mild, 35.59% moderate, 12.05% severe, and 2.40% critical. Regarding symptoms of those with a re-positive test, 2238 of 2466 re-positive cases were asymptomatic at the time of receiving a re-positive test result. Patients with asymptomatic symptoms were placed under medical observation. For those with symptoms, 193 (7.83%) patients had fever, cough, or shortness of breath. Specifically, 158 (6.41%) patients had a fever, 59 (2.39%) patients had a cough, and 18 (0.73%) patients had shortness of breath, 32 (1.30%) patients had fever and cough, 1 (0.04%) patient had cough and shortness of breath, and 9 (0.36%) patients had fever and shortness of breath. No patients had these three symptoms at the same time, and 11 of the 2466 patients passed away (not due to COVID-19).In total, 20,280 patients were included in the retrospective analysis. Among them, 2466 12.16%) were re-positive for SARS-CoV-2 after they were discharged from the hospital. The demographic and epidemiological characteristics of these patients were similar to those who did not have a re-positive test  threat assessment brief  describeSecond, some false positives and false negatives in our study were included. The Foundation for Innovative New Diagnostics (FIND)  conducteThird, limited patient factors were collected in this study. The results showed that sex and hospital stay of the original infection are related to having a re-positive test. Because many potential confounding factors were not analyzed, these results need to be verified using a more complete dataset.This retrospective study in Wuhan clarifies the basic characteristics of recovered COVID-19 patients with a re-positive PCR test. Furthermore, it was determined that these individuals are likely not infectious.Additional file 1.Additional file 2.


Clostridioides difficile is responsible for various intestinal symptoms from mild diarrhea to severe pseudomembranous colitis and is the primary cause of antibiotic-associated diarrhea in adults. Metronidazole was the first-line treatment for mild to moderate C. difficile infections for 30 years. However, clinical failure and recurrence rates of metronidazole is superior to oral vancomycin and metronidazole is now recommended only as an alternative to vancomycin or fidaxomicin, for an initial non-severe infection. The mechanisms of treatment failure and infection recurrence remain unclear. Given the poor fecal concentrations of metronidazole, the bacteria may be exposed to subinhibitory concentrations of metronidazole and develop adaptation strategy, which is likely to be the origin of an increase in treatment failures. In this study, a proteomic approach was used to analyze changes in the proteome of two strains with different levels of susceptibility to metronidazole in the presence of subinhibitory concentrations of this antibiotic. The two strains were grown to stationary phase: CD17-146, a clinical C. difficile isolate with reduced susceptibility to metronidazole, and VPI 10463, a metronidazole susceptible strain. Our study revealed that, whatever the strain, subinhibitory concentrations of metronidazole modified the amount of proteins involved in protein biosynthesis, glycolysis, and protection against stress induced by metronidazole, as well as in DNA repair. Several proteins involved in stress response are known to be synthesized under the control of Sigma factor B, which suggests a close link between Sigma factor B and metronidazole. Interestingly, impact of metronidazole on protein production for VPI 10463 strain differed from CD17-146 strain, for which the amount of two proteins involved in biofilm formation of CD17-146 were modified by metronidazole. Clostridioides difficile is a Gram-positive, spore forming and obligate anaerobic bacterium responsible for post-antibiotic diarrhea with a spectrum of clinical signs, ranging from self-limiting diarrhea to life-threatening pseudomembranous colitis. The C. difficile infection (CDI) has become the most common cause of healthcare associated infections in the United States, and the most frequent hospital-acquired intestinal infection in Europe and worldwide  or [MIC/2], RNAs were extracted using Trizol Reagent (Thermo Fisher Scientific) and RT-qPCR was realized as described by Batah et al. [ccpA gene was used as reference gene, as described in a previous study of Kint et al. [h et al. . RNA quat et al. . Normali-1 for VPI 10463 and 1 μg.mL-1 for CD17-146. However, the initial MIC of the CD17-146 strain was 2 μg.mL-1 as determined by ETEST®.The MIC of MTZ observed was 0.5 μg.mLC. difficile has been previously described by Peláez et al [-1. Most C. difficile susceptible strains have MIC ≤ 0.5 μg.mL-1 (https://mic.eucast.org/Eucast2/regShow.jsp?Id=21294). We considered CD17-146 as a strain with reduced susceptibility.Such difference in MIC results can be explained by the use of different methods (E-TEST and broth dilution). Another possible factor that might have changed the susceptibility of CD17-146 to MTZ is the storage at -80°C. Indeed, the phenomenon of unstable MIC of MTZ for ez et al . In thei5 CFU.mL-1 of C. difficile without MTZ or supplemented with 0.125, 0.25, or 0.5 μg.mL-1 of MTZ. We found that subinhibitory concentrations of MTZ had a direct inhibitory effect on the bacterial growth for both strains (-1) and MIC/2 (0.5 μg.mL-1), respectively. However, for VPI 10463 lag phase was only prolonged for 2 and 6 h in the presence of MTZ at MIC/4 (0.125 μg.mL-1) and MIC/2 (0.25 μg.mL-1), respectively. The enumeration of bacterial viable cells confirmed the results observed by measuring OD600nm and showed that lag phase for the CD17-146 strain was 3-fold and 1.3-fold longer than for VPI 10463 at MIC/4 and MIC/2 respectively, while the length of lag phase was similar between the two strains without MTZ. In addition, without MTZ, the growth rates of CD17-146 and VPI 10463 were similar . In contrast, in the presence of MTZ, strain CD17-146 seemed to grow more slowly than VPI 10463 at MIC/2. During the first 4 h of the exponential phase, the growth rates for VPI 10463 were 2.02 ± 0.27 h-1 at MIC/4 and 2.14 ± 0.52 h-1 at MIC/2, while for CD17-146, the growth rates were 1.74 ± 0.1 h-1 at MIC/4 and 1.21 ± 0.1 h-1 at MIC/2. However, there were no statistically significant differences between the growth rates of the two strains with or without MTZ. Slow-growing sub-populations with MTZ reduced susceptibility appeared after prolonged exposure of susceptible clinical isolates to MTZ in vitro. This selection process was sometimes reversible after passage in the absence of metronidazole; however, some slow-growing mutants converted to stable high-level resistance [The dynamic of bacterial growth was monitored in liquid BHISG medium with a start inoculum of 10 strains . This efsistance .C. difficile, a proteomic approach was used to analyze proteome profiles of strains CD17-146 and VPI 10463. These two strains were grown 18 h to stationary phase in the presence of MTZ at subinhibitory concentrations. All the cultures of VPI 10463 strain had an OD600nm of 1.4, the amounts of viable cells were 107, 2 x 107 and 9 x 107 CFU for the culture without MTZ, with MTZ at MIC/4 or MIC/2, respectively. For CD17-146, the cultures had an OD600nm of 1.2 with 2 x 107, 4 x 107 and 9 x 107 CFU for the culture without MTZ, with MTZ at MIC/4 or MIC/2, respectively. These results suggested that the state of the cultures after 18 h of growth were approximately similar without or with the MTZ whatever the concentration.To define more precisely the effects of MTZ on Bacterial proteins in the cultures were extracted using glass beads. Tryptic digests of samples were analyzed by liquid chromatography combined with mass spectrometry. Using the X!tandem pipeline, we identified 1049 proteins with at least 2 peptides identified over all samples with a peptide false discovery rate (FDR) of 0.05%, and a protein FDR of 0%. Among them, we found 629 proteins whose production was significantly different with minimal fold change set at 1.5. A heatmap was created based on these proteins to map the behaviors of the two strains.Analysis revealed that the proteomes of the two strains CD17-146 and VPI 10463 in the absence of MTZ belonged to the same cluster of the heat map, as they showed more similarities among all profiles . The proTo try to identify proteins involved in MTZ-stress response for each strain, we analyzed the proteins whose production was significantly different to focus on specific changes of proteins involved in cell envelope homeostasis, biofilm formation, protection against stress induced by MTZ and central metabolism.C. difficile proteins involved in cell wall metabolism. For both strains, we observed an increased production of proteins implicated in the production of the disaccharide-pentapeptide required for peptidoglycan synthesis  or its association with a lipid carrier (UppS) and glutamate racemase (MurI) involved in synthesis of precursors of the disaccharide-pentapeptide. These proteins were detected in the presence of MTZ only, reaching the highest number of spectra at MIC/4. In contrast, the amount of MurA enzyme, which adds an enol-pyruvyl to UDP-N-acetylglucosamine, decreased slightly 1.8 and 1.4 –fold for VPI 10463 and CD17-146 respectively at both concentrations of MTZ MTZ modified the production of cwp84 mutant strain grew slower and elaborated biofilms with increased biomass compared with the parental C. difficile 630Δerm strain [Interestingly, we observed in the presence of MTZ at MIC/2 a 3-fold decrease in the amount of Cwp84 in CD17-146 instead of a 2-fold increase in VPI 10463 . Cwp84 im strain . In vitrm strain .Streptococcus mutans. Interestingly, PdxR is known to have a role in biofilm formation of S. mutans since the pdxR mutant forms significantly fewer biofilm compared to its parental strain [We also observed a 3-fold increased amount of a putative aminotransferase for CD17-146 strain at MIC/2, but not for VPI 10463 . This prl strain . These dl strain . FurtherB. fragilis and H. pylori revealed that several proteins involved in electron transfer reactions  are important for the reductive activation of MTZ [The addition of subinhibitory concentrations of MTZ led to differential production of electron transport and redox-active proteins in both VPI 10463 and CD14-146. It is well known that activation of MTZ requires a reduction under sufficiently low redox potential in anaerobic organisms . Studiesn of MTZ ,52.H. pylori, C. perfringens and Bacteroides spp. [C. difficile.Pyruvate ferredoxin oxidoreductase (PFOR) together with ferredoxine (Fd) catalyzes the CoA-dependent decarboxylation of pyruvate to acetyl-CoA. PFOR/Fd couple is the only one with a low enough redox potential capable of reducing MTZ in anaerobic bacteria. The prodrug MTZ is activated to its toxic, radical state by the electrons transferred to the amine group of MTZ from Fd, which is itself reduced by the key metabolic enzyme PFOR . The decdes spp. . The amodes spp. . These rTo establish alternative route for pyruvate utilization, the two strains upregulated pyruvate-formate-lyase (PflD and PflB). The production of PflD in strain CD17-146 was enhanced 13- and 10-fold, respectively at MIC/4 and MIC/2, while PflD was only detected at MIC/4 in strain VPI 10463 . The amoEffect of MZT addition on the production of proteins involved in protection from oxidative/nitrosative stress and thiol homeostasis.Reductive activation of the nitro group of MTZ results in the formation of nitro free radical leading to cytotoxicity. Moreover, as oxygen has a higher affinity for electrons than MTZ, it has been shown that an electron from the nitroso-radical can be removed by oxygen and MTZ is regenerated. This “futile cycling” process generates toxic oxygen radicals that can induce DNA strand breaks. Then, in addition to direct nitrosative stress, MTZ may also indirectly accelerate the damage due to oxidative stress .Our data indicated higher production of other redox-active proteins in both VPI 10463 and CD17-146 with subinhibitory concentrations of MTZ, including anaerobic nitric oxide reductase (NorV), which is associated with protection against nitrosative/oxydative stress . The pro2- and H2O2-reductases, which have a key role to the ability of C. difficile to grow in the presence of low oxygen tension [Other proteins implicated in protection against oxidative/nitrosative stress such as reverse-rubrerythrins (RevRbr) and hydroxylamine reductase (Hcp) were also differentially produced. The two RevRbrs increased 3- fold at MIC/4 for VPI 10463. A recent study showed that RevRbrs are O tension . On the C. difficile isolate [It is worth noting that the TrxAB system, one RevRbr and NorV proteins, which are believed to be associated with protection against the effect of nitric oxide, ROS and oxygen were more produced in a stable, metronidazole-resistant  isolate . FurtherFor both strains, production of proteins involved in DNA repair also increased after treatment with MTZ. One such protein is the excinuclease UvrA (UvrABC repair system), which is involved in the repair of DNA lesions. Without MTZ this enzyme was under detection threshold, while its amount strongly increased following addition of MTZ at MIC/4 . We alsoB. fragilis and H. pylori [E. coli mutant deficient in recA were 10-fold more susceptible to MTZ than parental strains [C. difficile.Another important DNA repair protein, RecA, was more produced in both strains. In the absence of MTZ, RecA was undetectable while its amount increased in the presence of MTZ and became detectable at MIC/4 and MIC/2 . RecA is. pylori ,25. In a strains . It woulVarious cellular stress-related proteins were also more synthesized after treatment with MTZ . The LonC. difficile stressed with sub lethal concentrations of MTZ, vancomycin, or fidaxomicin in exponential growth phase [In the presence of subinhibitory concentration of MTZ, it was worth mentioning changes in synthesis of proteins involved in translation pointing to a substantial reprogramming of protein production. Indeed, the amounts of 3 elongation factors  and several tRNA synthetases  were found to drastically increase in both strains in the presence of MTZ at MIC/4. Conversely, their production decreased at MIC/2 compared to MIC/4 . These cth phase . In addith phase .C. difficile combined amino acid fermentation via electron bifurcation to membrane potential generating processes at the Rnf complex that couples the NADH-dependent reduction of enoyl-CoA obtained from amino acid catabolism to the reduction of ferredoxin. Two electrons derived from NADH are distributed to two acceptors, enoyl-CoA and ferredoxin. The free energy resulting from redox potential difference between ferredoxin and NAD+ is used to transport ions across the membrane and to generate ATP. This reductive Stickland metabolism is known to be the highly adaptive metabolism of C. difficile when normal substrate level phosphorylation suffers from a deficiency of ATP [C. difficile in the presence of MTZ.Several enzymes involved in reductive Stickland metabolism (mainly Leucine catabolism) were more produced at MIC/4 for VPI 10463 and at both MIC/4 and MIC/2 for CD17-146  . At MIC/y of ATP . The higClostridium pasteurianum is significantly inhibited by a number of inhibitors of glycolysis  [Additionally, it should be noted that the amount of several proteins involved in glycolysis were modified after MTZ stress in both strains. The quantity of several enzymes decreased about 2-fold in the presence of MTZ: glucose-6-phosphate isomerase (Pgi), glyceraldehyde-3-phosphate dehydrogenase (GapA), fructose-1,6-bisphosphate aldolase (Fba), enolase (Eno) . The droic acid) .Bacillus stearothermophilus were induced by ADP and AMP, respectively when cell energy (ATP) went down [Conversely, some enzymes of glycolysis involved in substrate phosphorylation were upregulated under the same conditions: the phosphoglycerate kinase (Pgk), phosphoglyceromutase (GpmI), phosphofructokinase (Pfk) and pyruvate kinase (Pyk) . For CD1ent down ,60. Our ) and 3-hydroxybutyryl-CoA dehydrogenase (Hbd) involved in butyrate production decreased for both strains, especially at MIC/4: Bcd amount decreased 3- and 6-fold, the amount of Hbd decreased 4- and 10-fold for VPI 10463 and CD17-146, respectively Click here for additional data file.


Palatinose-based alternative sweeteners significantly improved glucose tolerance in rats. However, significant differences in the blood glucose levels were not observed among the Palatinose-based alternative sweeteners. In the clinical study, 14 healthy volunteers (21.4 ± 1.3 years) consumed glucose or Palatinose-based alternative sweeteners (50 g). At 60 min, when Palatinose-based alternative sweeteners were ingested, blood glucose was significantly lower compared to when glucose was ingested . The glycaemic index of Palatinose-L, Palatinose-IS and Palatinose-FOS was 43.9, 58.1, and 49.2, respectively. Palatinose-based alternative sweeteners could help maintain health as the postprandial blood glucose levels are constantly maintained owing to slow hydrolysis.Animal and clinical studies were performed to determine whether Palatinose-based alternative sweeteners with increased sweetness contributed to blood glucose elevations. In the animal study, male Sprague-Dawley rats (6 weeks old) received an oral load of 2 g of glucose or Palatinose-based alternative sweeteners per kilogram of body weight. Thirty minutes after the glucose load, the rat blood glucose levels in the Palatinose-based alternative sweetener groups were significantly lower than those in the glucose groups ( In 1980, Palatinose was first commercialized as a sweetener by the Japanese. Unlike xylitol and sorbitol, which are both sugar alcohols, Palatinose is completely hydrolysed by disaccharidase in the human small intestine, thus demonstrating no side effects such as flatulence or diarrhea after intake of large quantities  was added and allowed to react at 30°C for 20 h. After the enzymatic reaction was complete, the enzyme was inactivated by increasing the temperature to 90°C for 30 min. The treatment up to this stage generated Palatinose-L. Palatinose-IS was derived from invertase-treated Palatinose-L. Palatinose-FOS was prepared from Palatinose-L treated with fructosyltransferase. Both reactions were performed at 55–60°C for 20–24 h. The reactions were inactivated by increasing the temperature to 90°C for 30 min, followed by the addition of activated carbon and stirring at 65°C for 2 h. Subsequently, the solutions were filtered through a 0.5-μm filter, then passed through a 0.22-μm filter, and finally concentrated to 70°Brix. Table 1 in In this study, Palatinose-L, Palatinose-IS, and Palatinose-FOS were provided by Neo Cremar Co. Ltd. . Briefly, sugar (400 g) was added to water (600 ml) and stirred at 75°C. After adjusting the pH of the aqueous sugar solution to 6, The study protocol was reviewed and approved by the Korea University Animal Care Committee, Korea (KUIACUC-2018-7). Six-week-old male Sprague-Dawley rats (312.67±4.32 g) were obtained from the Central Lab, Animal Inc. . They were individually housed in plastic cages with stainless steel grate floors; the temperature was maintained at 24 ± 1°C, with 60% atmospheric humidity, and a 12-h light/dark cycle. After an adaptation period, the rats were categorized into four groups (six rats/group) based on blood glucose and body weight. Following an overnight fast, the rats received an oral load of 2 g of glucose or Palatinose-based alternative sweeteners  per kilogram of body weight. Glucose levels were measured at fasting and at 30, 60, 90, and 120 min using the glucose oxidase method in venous blood drawn from the tail vein. Blood samples were withdrawn onto test strips and analyzed using an Accutrend Sensor .The clinical study protocol was approved by the Ethics Committee for Human Experimentation of the Jeonju University and was conducted in accordance with its rules and regulations (jjIRB-181115-BR-2018-1107). A within-subject and repeated-measures design was used. The clinical study was conducted in accordance with the procedure recommended by the Food and Agriculture Organization of the United Nations (FAO)/WHO . IndividThe GI was calculated in accordance with the procedure indicated by Kawai et al.  based onAll statistical analyses were performed using the Statistical Package for Social Sciences ver. 25.0 . The differences in the results between sweeteners were statistically evaluated by one-way analysis of variance (ANOVA) and Tukey's multiple tests. All data were two-sided with a 5% significance level and are reported as the mean ± standard error of the mean (SEM).p < 0.05). Palatinose-based alternative sweeteners significantly improved glucose tolerance in the rats. However, significant differences in blood glucose levels were not observed among the Palatinose-based alternative sweeteners. After 120 min, no significant differences were observed in the blood glucose levels between the glucose group and the Palatinose-based alternative sweetener groups.p < 0.05) lower than those after the oral intake of glucose (154.8 ± 4.6 mg/dL). After 60 min of the intake of glucose and Palatinose-based alternative sweeteners, the blood glucose levels were significantly (p < 0.05) different. After 120 min, the blood glucose levels in the Palatinose-based alternative sweetener groups returned to the levels observed in the fasting state; however, the blood glucose levels in glucose group remained elevated compared to those in the fasting state. The GI was calculated by the response curves of glucose; the results are shown in p < 0.05). The GI for Palatinose-L (43.9 ± 19.5) than for Palatinose-IS (58.1 ± 30.2) or Palatinose-FOS (49.24 ± 10.1) were significantly lower compared to glucose (p < 0.001).Palatinose is regarded as a healthier sweetener than sucrose for several reasons. Reportedly, orally ingested Palatinose minimally increases blood glucose and insulin levels and, additionally, suppresses the blood glucose elevations induced by other carbohydrates, such as glucose, sucrose, and dextrin –14. SeveRecent data support the preventive potential of a low GI diet against the development of type 2 diabetes and cardiovascular disease . In addiRats and humans receiving Palatinose-based alternative sweeteners demonstrated blood glucose levels and area under the curve results significantly different from those observed with glucose administration. In this study, the oral doses of Palatinose-based alternative sweeteners improved postprandial hyperglycaemia. Palatinose-L, Palatinose-IS, and Palatinose-FOS are expected to play a role as ideal sugar substitutes in line with the recent trend toward sugar reduction. These substitutes can be clarified as sweeteners suitable for individuals with diabetes due to their inherently low GI. Therefore, they showed the potential as an alternative sweetener to control blood sugar after eating.All datasets generated for this study are included in the article/The clinical study was approved by the Ethics Review Board of Jeonju University, Korea (jjIRB-181115-BR-2018-1107). The patients/participants provided their written informed consent to participate in this study. The protocol for the animal study was reviewed and approved by the Korea University Animal Care Committee, Korea (KUIACUC-2018-7).EJ made a substantial contribution to drafting the manuscript and interpreting and analyzing the data. KJ searched for study sites, prepared the manuscript, and conducted the study. KJ and K-BH designed the study, performed the statistical analysis, and responded to editorial and reviewers' comments. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Twelve students experienced symptoms of acute respiratory infection (ARI) at a training base in Beijing from August 26 to August 30, 2015. We investigated the cause of this ARI outbreak.In partnership with the local center for disease control, we collected a total of twelve pharyngeal swab specimens as well as demographic information for the affected patients. We used multiplex real-time PCR to screen for sixteen common respiratory viruses in these samples. To isolate HAdV, we inoculated Hep-2 cells with the human adenovirus (HAdV)-positive samples and then carried out sequencing and phylogenetic analysis of the hexon, fiber, and penton genes of the isolated adenoviruses. In addition, we analyzed the entire genome of one strain isolated from the index case to identify single-nucleotide substitutions.We identified ten HAdV-positive students using multiplex real-time PCR. None of the students were co-infected with other viruses. We successfully isolated seven HAdV strains from the pharyngeal swab specimens. The coding sequences of the hexon, fiber, and penton genes of these seven HAdV strains were identical, suggesting that they represented seven strains from a single virus clone. One HAdV isolate obtained from the index case, BJDX-01-2015, was selected for whole genome analysis. From this isolate, we obtained a 34,774-nucleotide sequence. The genome of BJDX-01-2015 clustered with HAdV-B55 in phylogenetic analyses and had 99.97% identity with human adenovirus 55 isolate HAdV-B/CHN/BJ01/2011/55 (GenBank accession no. JX491639).We identified HAdV-B55 as the strain associated with the August 2015 ARI outbreak at a training base in Beijing. This was the first reported outbreak in Beijing due to HAdV-B55. Continuous surveillance of respiratory adenoviruses is urgently needed to understand the epidemiological and evolutionary features of HAdV-B55, and an epidemiological modeling approach may provide further insights into this emerging public health threat. Furthermore, the clinical laboratory data from this outbreak provides important reference for the clinical diagnosis and may ultimately aid in informing the development of strategies to control and prevent respiratory tract infections caused by HAdV-B55. HAdVshttp://hadvwg.gmu.edu/) [HAdV was first reported as a viral pathogen in 1953 . Since tmu.edu/) –12. Adenmu.edu/) .Different HAdV species display various tissue tropisms that correlate with the different clinical symptoms of infection . HAdV spHAdVs have been associated with previous outbreaks of ARI. HAdV-B3 and HAdV-B7 cause frequent outbreaks in the United States . In AsiaIn China, HAdV-B3 and HAdV-B7, two HAdV species B subtypes, are common causes of epidemic ARI outbreaks –24. In 2Here we describe an outbreak of ARI caused by HAdV-B55 at a training base in the Daxing District of Beijing, China. To help identify the causative pathogen, we collected pharyngeal swab specimens from the affected students and carried out molecular detection and typing, phylogenic analysis, and whole-genome sequencing. This is the first reported outbreak of ARI in Beijing due to HAdV-B55.On August 31, 2015, local public health authorities were informed about an outbreak of ARI among young students at a training base located in the Daxing District of Beijing. The training base consisted of two three-floor buildings for teaching and three three-floor dormitories with eight persons to a room. The training base recruits only male middle school graduates. Approximately 3000 students majoring in Mathematics, Chinese, and English were enrolled in a total of sixty classes. The training base employs 100 full-time staff members.On August 26, 2015, one student reported symptoms of an ARI and had a body temperature of 38.4 °C. By August 30, a total of 12 ARI patients from the same class were reported by the local hospital. For the purposes of our analysis, we defined ARI cases as individuals with a body temperature over 38.0 °C and with at least one symptom of a respiratory tract infection, such as cough or sore throat. On August 31, the Daxing District Center for Disease Prevention and Control (CDC) began an epidemiological investigation, collecting demographic, clinical and laboratory data. Under the guidance of the CDC, the training base took precautionary measures, including quarantining the affected students, carrying out a routine cleaning and disinfection of living quarters, and morning body temperature checks. No further new cases were reported by September 08, 2015.Pharyngeal swab samples were obtained from each of the twelve students infected in this ARI outbreak. The specimens were collected in 3ml vials containing viral transport medium and quickly transported on ice to the laboratory of the Daxing District CDC. The specimens were stored at − 80 °C until further use. Patient information and laboratory results are shown in Table Nucleic acids were extracted from 140 μl of each of the clinical samples using QIAamp Viral RNA mini Kits  according to the manufacturer’s instructions. Pharyngeal swab specimens were screened for 16 common respiratory pathogens via real-time PCR multiplex assays using commercial kits  as described by Shi W., et al. . The 16 2 incubator for 1 week following standard protocols [Hep-2 cells were inoculated with HAdV PCR-positive specimens and cultured in high-glucose Dulbecco’s Modified Eagle Medium  containing 2% fetal bovine serum , 100 U/mL penicillin , and 100 mg/mL streptomycin  at 37 °C in a 5% COrotocols . The culrotocols .Molecular typing of HAdVs was performed via conventional PCR using specific primers targeting the complete coding sequences of the hexon, fiber, and penton genes . Viral DTo further analyze mutations in the genome sequences of the viruses isolated in this ARI outbreak, we sequenced the whole genome of one isolate from the index case using the Sanger method. Targeted 1-2 kb segments that covered the entire genome with overlapping sequences of about 200 bp were amplified by PCR. The 5′ and 3′ ITRs of the genome were amplified and cloned into a plasmid T-vector and then sequenced. A set of 47 pairs of primers was designed in-house to amplify the whole genome according to the reference sequence (GenBank accession no. FJ643676) and then used for separate PCRs. Primer sequences are available upon request.Whole-genome sequencing segments were amplified using high-fidelity polymerase  using 1.0 mM of each primer. PCRs were carried out using a BioRad thermocycler  with the following protocol: 94 °C for 5 min., followed by 35 cycles of 50 s. at 94 °C, 50 s. at appropriate annealing temperature for separate primers, 3 min. at 72 °C, and a final extension step of 72 °C for 10 min.The amplified segments were purified and bi-directionally sequenced. Gaps and ambiguous sequences were PCR-amplified using new primers and re-sequenced. DNA sequence fragments were assembled using the SeqMan program implemented in DNASTAR Lasergene 7.0  into a single contig. The genomic sequence determined in this study was deposited in GenBank under accession number MK886831.https://blast.ncbi.nlm.nih.gov/). Multiple nucleotide sequence alignments were performed using the ClustalW program implemented in BioEdit. Comparisons between the whole genome sequence of the BJDX-01-2015 virus strain and those of other types of HAdVs were generated using CLC Genomics Workbench .Nucleotide sequence homologies were identified using the Basic Local Alignment Search Tool . One thousand bootstrap replications were used to estimate distances. Bootstrap values greater than 70% are shown for selected nodes in Fig. . Reported students were from the same class but living in six different dormitory rooms. The outbreak lasted for 6 days.On August 26, 2015, a 15-year old male student developed a case of ARI, with a peak body temperature of 38.4 °C. By August 31, a total of 12 male students were infected. No females were infected. The mean age of the infected students was 15.4 years . The distribution of daily cases is shown in Fig. 1. All 12 infected individuals had a fever; 9 (75%) students had a sore throat, and 8(66.67%) students had a headache. Other symptoms reported by the patients were cough, body ache, stuffy nose, and diarrhea. All affected students had normal white blood counts. Most of the infected students were treated in outpatient clinics; only one patient, who had non-severe pneumonia, was hospitalized.The clinical symptoms of the infected students are described in Table 19/L .The index case (ID No.1) was diagnosed as having an upper respiratory infection with a peak temperature of 38.4 °C, a neutrophil count of 72.2% , percentage of lymphocytes of 22.2% , and white blood cell count of 7.8 × 109/L . A chest x-ray showed patchy shadows on the right lung of the hospitalized student.The hospitalized student (ID No.6) had a peak temperature of 40.0 °C accompanied by a cough, headache, sore throat, and diarrhea. He had a neutrophil count of 78.6% , a percentage of lymphocytes of 17.8% , and a white blood cell count of 5.04 × 10A total of 12 respiratory samples were obtained from the 12 students. Ten specimens were shown to be HAdV-positive using multiplex PCR . None of the 10 HAdV-positive patients were co-infected with other respiratory viruses.To isolate viruses, we inoculated Hep-2 cells with the HAdV-positive samples and isolated seven HAdV virus strains. Using typing primers, which allow for the determination of viral type, we sequenced the hexon, fiber, and penton genes in the seven HAdV strains .The hexon 2841 bp), fiber (978 bp), and penton (1674 bp) sequences from the seven HAdV isolates were 100% identical, suggesting that this outbreak was caused by a single viral strain. We then compared the hexon, fiber, and penton sequences of one of the viral strains isolated from the index case , with other HAdV-B55, HAdV-B11 and HAdV-B14 strains. Based on BLAST analysis, the hexon, fiber, and penton genes were 99.6, 100, and 100% identical to the genes of the HAdV-B55 reference strain QS-DLL in China (GenBank accession number FJ643676), respectively,. The hexon, fiber, and penton genes were each 100%, identical to the genes of the isolate HAdV-B/CHN/BJ01/2011/55 . The complete genome of BJDX-01-2015 was 34,774 nucleotides in length and had 137-bp inverted terminal repeat sequences in the 5′- and 3′- untranslated regions (5′-UTR and 3′-UTR).To investigate the genetic relationships between isolate BJDX-01-2015 and other HAdV strains, we constructed phylogenetic trees  were observed in the coding region of protein VI , which was isolated from a patient with severe CAP in a previous study by Bin Cao et al. at Beijing in 2011 , 43. TheIn our study, the strain of BJDX-01-2015 was obtained from the index case (ID#1), who presented with an upper respiratory infection. Furthermore most of the infected students were treated in outpatient clinics, and only one patient with non-severe pneumonia was hospitalized. The isolate of HAdV-B/CHN/BJ01/2011/55 was obtained from a patient with severe CAP in a previous study by Bin Cao et al. at Beijing , in whicThese findings imply that severe ARIs were not simply caused by HAdV-B55 virus strains themselves but also depend on the conditions of the hosts, such as the individual’s age, general state of health, and the presence of co-morbidities or additional infections.In this outbreak, we also found that for both the index case and the hospitalized case neutrophils increased and /or lymphocytes in the peripheral blood decreased. Studies on other respiratory viruses, such as influenza virus, respiratory syncytial virus, or human rhinovirus, have shown that an increase in neutrophils has a significant role in limiting virus replication , 45. ThuMost of the mutations at the amino acid level in BJDX-01-2015 were observed in the coding regions of protein VI. During the replication of HAdVs, protein VI functions as an adaptor to shuttle the hexon protein to the nucleus, where virus assembly occurs . WhetherThe increasing frequency of ARI outbreaks due to HAdV-B55 suggests that this re-emergent virus poses a serious threat to public health. It is therefore urgent that the local CDC improve epidemiological and virological surveillance of HAdV-B55.We identified HAdV-B55 as the cause of a recent localized ARI outbreak. This incident was the first reported outbreak in Beijing that can be attributed to this re-emergent virus. Our findings show that the risk of an HAdV-B55 epidemic should be paid more attention in Beijing, the capital of China, with a population of more than 20 million. Continuous surveillance of respiratory adenoviruses is an urgent need to understand the epidemiological and evolutionary features of HAdV-B55 and could also find value in an epidemiological modeling approach. We also found that the clinical laboratory data from this outbreak provides important reference for clinical diagnosis and may ultimately aid in informing the development of strategies to control and prevent respiratory tract infections caused by HAdV-B55 .


The control of balance depends upon multiple neurophysiologic systems including the activation of cortical brain regions . The excitability of this region, however, is diminished in people with CAI. In this pilot double-blinded randomized controlled trial, we tested the effects of high-definition transcranial direct current stimulation (HD-tDCS) designed to facilitate the excitability of M1 and S1 in combination with short-foot exercise (SFE) training on proprioception and dynamic balance performance in individuals with CAI. (2) Methods: Thirty young adults completed baseline assessments including the Active Movement Extent Discrimination Apparatus (AMEDA), Joint Position Reproduction (JPR) test, Y-balance test, and the Sensory Organization Test (SOT). They were then randomized to receive a four-week intervention of SFE in combination with tDCS  or sham  stimulation. Baseline assessments were repeated once-weekly throughout the intervention and during a two-week follow-up period. (3) Results: Twenty-eight participants completed this study. Blinding procedures were successful and no adverse events were reported. As compared to the control group, the HD-tDCS+SFE group exhibited significant improvements in the JPR test, the Y balance test, and the SOT at different time points. No group by time interaction was observed in AMEDA test performance. (4) Conclusions: HD-tDCS combined with SFE may improve dynamic balance and proprioception in CAI. Larger, more definitive trials with extended follow-up are warranted. Chronic ankle instability (CAI) is highly prevalent in people who have suffered an ankle sprain ,2 and isTraditional rehabilitation for CAI focuses primarily on peripheral neuromuscular function of the ankle . HoweverTranscranial direct current stimulation (tDCS) is one promising noninvasive approach that modulates the excitability of cortical regions by transferring small electrical currents via scalp electrodes. Recent studies have demonstrated that tDCS improves both static and dynamic balance in younger and older adults as well as those with neurological diseases ,13. KamiTraditional tDCS, while a promising therapeutic strategy, utilizes relatively large sponge electrodes that generate diffuse electric fields. This leads to relatively high inter-subject variance in cortical target engagement and tDCS-induced functional improvements . High-deThirty young adults with CAI  were recruited. Inclusion criteria were: (1) self-reported history of the first acute ankle sprain more than one year ago; (2) experience of two or more sprains to the same ankle in the three months prior to study; (3) at least two episodes of slack or ‘giving-way’ associated with the same ankle in the six months prior to participation; (4) a Cumberland Ankle Instability Tool (CAIT) score less than 24  [Sample size estimation for this study was based upon the results from two previous studies ,19. One In this double-blinded and sham-controlled study, participants were randomized to receive 12 sessions of SFE combined with either HD-tDCS or sham  stimulation over a four-week period . Functional assessments, consisting of proprioceptive and dynamic balance tests, were assessed at baseline, and after the first, fourth, eighth, twelfth session of intervention . The same tests were repeated at one and two weeks following the last session of intervention .HD-tDCS was delivered by the Neuroconn system . Finite element model analysis included in the SimNIBS software was used to optimize the tested montage  ,21. The During HD-tDCS, the current was increased from 0 mA to 2 mA over the first 30 s, maintained at this level for 19 min, and then gradually decreased to 0 mA over 30 s. For the sham stimulation, the same electrode location was used, but the current was ramped back down to 0 mA after the initial ramp-up phase. This process is commonly used as a control intervention because cutaneous sensations associated with tDCS typically fade within the first minute of stimulation . After eDouble-blinding to intervention assignment was ensured by using a ‘blinded’ mode in the device software. The HD-tDCS or sham protocol was loaded into the software for each participant by study staff uninvolved in any other aspects of study. Neither the participant nor the researcher thus knew the type of stimulation being administrated.The goal of the SFE was to shorten the foot in the anterior–posterior direction by drawing the metatarsals to the heel without flexing the toes. This relatively novel proprioception training strategy has been shown to improve foot muscle strength and dynamic stability more than conventional proprioceptive sensory exercise . Four blAMEDA  was used® isokinetic dynamometer . This test has been proven to reliably evaluate ankle joint position perception [The joint position reproduction (JPR) test of proprioception  was asserception . ParticiThe Y-balance test, an modified version of the Star Excursion Balance Test (SEBT), was used to measure dynamic postural control . This asThe SOT was completed using a Neurocom Smart Balance Master system  to quantify the relative role of proprioceptive, visual, and vestibular feedback to standing postural control . The SOTp < 0.05, 2-tailed. Two-way repeated-measures analysis of variance (ANOVA) models were used to examine the effects of SFE plus HD-tDCS on proprioception and dynamic balance function. Independent variables were group  and time . Primary dependent variables were the AMEDA score and the Y-balance composite reach score. Secondary outcomes included the JPR absolute error value and the SOT equilibrium score. Separate models were tested for each outcome. Fisher’s least significant difference (LSD) post-hoc testing was conducted to identify differences in factor means within significance ANOVA models. Partial eta squared was used to examine the effect size of the treatment.All statistical analyses were performed using SPSS statistical software . Statistical significance level was set as p = 0.833), indicating excellent blinding efficacy. No severe side effects were reported during the study (Twenty-eight of 30 participants completed this study . One parhe study . The ins(6156) = 16.240; p = 0.001; η2 = 0.384) was observed. Within the HD-tDCS group, post-hoc tests showed that compared to the baseline, the AMEDA score improved at Week-3 (p = 0.002) and that this improvement was sustained through Week-6 (p < 0.008). Within the sham group, compared to the baseline, an improvement appeared at Week-4 and Week-5 (p < 0.001).AMEDA performance is presented in (5130) = 2.344; p = 0.029; η2 = 0.102) at 15° of inversion, while no such interaction was observed at 10° of inversion or 15° of eversion.The JPR absolute error value is presented in p = 0.001). Within the HD-tDCS group, compared to the baseline, the absolute error value was lower at Week-3 and Week-6 (p < 0.038).At 15° of inversion, a significant difference was observed between the two groups at Week-2 (p < 0.001).For the other two variables, the post-hoc test only showed a time effect in the 15° of eversion condition. Within the HD-tDCS group, compared to the baseline, the absolute error value was lower in Week-5 and sustained in Week-6 ((6156) = 2.746; p = 0.044; η2 = 0.096) was observed in composite reach distance . Within the HD-tDCS group, compared to the baseline, the composite reach distance was significantly greater at Week-2 and such an increase was sustained through Week-6 (p < 0.041).A significant time × group interaction (Fdistance . Post-ho(6156) = 4.761; p = 0.002; η2 = 0.155), SOT5 (F (6156) = 4.030; p = 0.005; η2 = 0.134), and SOT6 (F(6156) = 2.586; p = 0.050; η2 = 0.090). A main effect of time was observed for SOT1 (F(6156) = 2.895; p = 0.011; η2 = 0.100). No significant effects of intervention, time, or their interaction were observed for SOT2 or SOT3.SOT equilibrium scores are presented in Fisher’s LSD comparisons revealed that within the HD-tDCS group, the performance of SOT4 significantly improved at Week-4 compared to the baseline and such improvement was maintained through Week-5 and Week-6 compared to the baseline. For SOT5, only the HD-tDCS group performance was greater at Week-1 compared to the baseline. This increase was sustained through Week-6. For SOT6, the performance in HD-tDCS group was significantly greater at Week-3 compared to the baseline, and this improvement was sustained through Week-6, but in the sham group, the improvement of SOT6 performance was only sustained at Week-5, and at Week-6, the improvement was eliminated.This randomized, sham-controlled, double-blinded pilot study indicates that SFE combined with HD-tDCS, compared to SFE combined with the sham stimulation, may result in significantly greater improvement in the performance on the Y-balance test, the SOT, and the JPR test with the ankle at 15° inversion in young adults with CAI. These results suggest that facilitating sensorimotor cortical excitability during CAI rehabilitative exercise may augment its beneficial effects on proprioception and dynamic balance performance. Larger, more definitive studies are thus warranted to confirm the results of this study.SFE combined with HD-tDCS or the sham stimulation each similarly improved proprioception as measured by the AMEDA test. HD-tDCS thus did not augment the effects of SFE in this cohort. This may be due to the underlying pathological mechanism of CAI. Diminished proprioception in CAI arises in part from reduced mechanoreceptor sensory afferent inputs and/or weakened postural reflex responses, which is mediated by the spinal cord . SFE itsHD-tDCS combined with SFE induced significantly greater improvements in the performance of JPR at 15° of ankle inversion (but not in 15° eversion or 10° inversion), suggesting that HD-tDCS may augment SFE-induced improvement of position discrimination ability to a certain extent. This is in line with previous studies. For example, Ahn et al.  showed tWe observed that the combination of HD-tDCS and SFE significantly improved the dynamic balance performance as assessed by the Y-balance test, compared to the SFE plus sham stimulation. Similar improvements were observed in the most difficult conditions of the SOT; that is, compared to the sham, HD-tDCS combined with SFE improved dynamic balance in SOT4, SOT5, and SOT6. Evidence suggests that the capacity to integrate multiple types of sensory information  is altered in individuals suffering from CAI. When standing on unstable ground, for example, healthy people are able to maintain balance via dynamic re-weighting of sensory inputs in order to compensate for the abnormal ankle proprioceptive input . Those wThis pilot study has several limitations. The sample size was small (n = 28) and a relatively short follow-up period was used . As SFE was combined with HD-tDCS or sham, the effects of each intervention along with study outcomes remain unknown. Finally, as spinal and subcortical circuits undoubtedly play an important role in proprioception and its incorporation into the balance control system, future effects are needed to determine the SFE along and in compensation with HD-tDCS on the integrity of these system components. Nevertheless, this pilot study demonstrated that HD-tDCS is a promising adjunct to rehabilitation exercise programming for younger adults with CAI.


Mappings to convert clinical measures to preference-based measures of health such as the EQ-5D-3L are sometimes required in cost-utility analyses. We developed mappings to convert best-corrected visual acuity (BCVA) to the EQ-5D-3L, the EQ-5D-3L with a vision bolt-on (EQ-5D V), and the Visual Functioning Questionnaire-Utility Index (VFQ-UI) in patients with macular edema caused by central retinal vein occlusion.We used data from Lucentis, Eylea, Avastin in vein occlusion (LEAVO), which is a phase-3 randomized controlled trial comparing ranibizumab, aflibercept, and bevacizumab in 463 patients with observations at 6 time points. We estimated adjusted limited dependent variable mixture models consisting of 1 to 4 distributions (components) using BCVA in each eye, age, and sex to predict utility within the components and BCVA as a determinant of component membership. We compared model fit using mean error, mean absolute error, root mean square error, Akaike information criteria, Bayesian information criteria, and visual inspection of mean predicted and observed utilities and cumulative distribution functions.Mean utility scores were 0.82 for the EQ-5D-3L, 0.79 for the EQ-5D V, and 0.88 for the VFQ-UI. The best-fitting models for the EQ-5D and EQ-5D V had 2 components (with means of approximately 0.44 and 0.85), and the best-fitting model for VFQ-UI had 3 components .Models with multiple components better predict utility than those with single components. This article provides a valuable addition to the literature, in which previous mappings in visual acuity have been limited to linear regressions, resulting in unfounded assumptions about the distribution of the dependent variable. •Adjusted, limited dependent variable mixture models with multiple components better predict utility using the EQ-5D-3L with and without vision bolt-on and Visual Functioning Questionnaire-Utility Index (VFQ-UI) than mappings with only 1 component. Previous mappings in visual acuity have considered only linear regression using ordinary least squares (1 component).•Our mappings can be used to predict 3 different measures of utility as a function of age, sex, and best-corrected visual acuity in both eyes. These variables are routinely included in economic evaluations of visual disorders. Mappings to convert clinical measures to health utilities may be required for economic evaluations in which either health utilities were not reported in the clinical effectiveness studies or in which there is a need to relate modeled clinical outcomes to health utilities in the long-term. Health utilities may be generated using generic preference-based measures such as the EQ-5D or more specific measures such as the Visual Functioning Questionnaire-Utility Index (VFQ-UI) in visual disorders.A multicenter phase 3 double-masked randomized controlled noninferiority trial comparing intravitreal therapy with ranibizumab (Lucentis) versus aflibercept (Eylea) versus bevacizumab (Avastin) for macular edema due to central retinal vein occlusion  was a three-arm study of 463 patients over a 100-week period.The EQ-5D asks patients to rate their health across 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. In the 3-level (3L) version, each dimension has 3 levels: no problems, some problems, and extreme problems.A bolt-on exists for the EQ-5D, which also asks patients about their vision. In the 5L version, there are 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. In the 3L version, there are 3 levels: no problems, some problems, and extreme problems. A scoring algorithm exists for the vision bolt-on to the EQ-5D-3L, whereby a decrement of 0.0378 is subtracted from the EQ-5D-3L score for patients who report some problems with vision and a decrement of 0.130 is subtracted from the EQ-5D-3L score for patients who report extreme problems with vision.The VFQ-UI was developed from the National Eye Institute Visual-Function Questionnaire-25, which contains 25 items with 5 or 6 response levels. The VFQ-UI asks patients to rate their health across 6 dimensions. Near vision, social vision, and distance vision each have 4 levels relating to the level of difficulty  that the patient has in specific activities. Role difficulty asks whether the patient is not limited, limited a little of the time, limited some of the time, or limited in how long they can work or do other activities. Vision dependency asks whether the patient does not have to stay home or has to stay home some, most, or all of the time. Mental health asks whether the patient does not worry or worries some, most, or all of the time about doing this, which will embarrass themselves or others.The primary outcome in LEAVO was the change in best-corrected visual acuity (BCVA) of the study eye measured using early treatment for diabetic retinopathy study (ETDRS) letter score from baseline to 100 weeks. The ETDRS chart consists of 14 rows of 5 letters, with an equal difficulty on each row but with decreasing size. For patients who could read 20 or more letters correctly at 4m, their BCVA score was the number of letters read at 4m plus 30. For patients who could read fewer than 20 letters correctly at 4m, their BCVA score was calculated as the total number of letters read correctly at 4m plus the total number of letters read correctly at 1m in the first 6 lines.LEAVO collected EQ-5D-5L, vision bolt-on, and VFQ-UI responses in addition to BCVA ETDRS scores for both eyes (among other measures) at weeks 0, 12, 24, 52, 76, and 100. We used the van Hout crosswalkThe EQ-5D-3L has a distinctive distribution, with a lower bound of –0.594 and an upper bound of 1. It displays a multimodal distribution with a mass of observations at 1 and a gap between 1 and the next-best health state . These properties mean that standard statistical models are often a poor fit, and so we used bespoke models developed for modeling EQ-5D-3L: adjusted limited dependent variable mixture models (ALDVMMs).ALDVMMs are flexible models that feature multiple components; each component’s distribution has different parameters. Additional variables predict the probability of each observation belonging to each component. We estimated ALDVMMs with 1 to 4 components. We included BSE BCVA, WSE BCVA, and the interaction between them ; age; and sex as independent variables to predict the EQ-5D, EQ-5D V, or VFQ-UI within the components. We considered BSE and WSE BCVA as determinants of component membership. We did not include the trial arm as an independent variable because there was no statistically significant difference between utility in the 3 arms in the trial,To compare results across models, we considered standard model fit measures/criteria such as mean error mean absolute error (MAE), root mean square error (RMSE), Akaike information criteria (AIC), Bayesian information criteria (BIC), and graphical methods for model selection in mapping.There were 2778 observations in total (6 time points for 463 patients). There were 2558 observations, which included data for age, sex, and BCVA in both eyes. Utility data were available for 2470 of these observations for the EQ-5D, 2321 for the EQ-5D V, and 2481 for the VFQ-UI. The distributions of EQ-5D, EQ-5D V, and VFQ-UI scores and for the BSE and WSE BCVA ETDRS scores are shown in https://doi.org/10.1016/j.jval.2020.03.008) demonstrated a statistically significant correlation (at the 5% level) between the variables.Descriptive statistics are shown in https://doi.org/10.1016/j.jval.2020.03.008) presents the fit statistics for the ALDVMM models for the EQ-5D V. As with the EQ-5D, the interaction term worsened the model fit, and using the BSE and WSE to predict component membership improved the model fit. The BIC was lowest for the 2-component model with component membership predicted by BSE and WSE, whereas the mean error, MAE, and RMSE were similar for the 2-, 3-, and 4-component models.We found that the EQ-5D and EQ-5D V were best predicted using 2-component models (the VFQ-UI using 3-component models) where utility within each component was a function of age, sex, and visual acuity in both eyes and the probability of component membership was a function of visual acuity in both eyes. Our mappings were designed for use in an economic model in macular edema secondary to CRVO, to allow utility to be predicted long-term from visual acuity.https://figshare.shef.ac.uk/articles/Utility_calculator_for_visual_acuity/9873731/1. As a generic measure of health, the EQ-5D allows comparisons across disease areas and is NICE’s preferred measure of utility for adults.We provide mappings for 3 measures of utility. An Excel tool that calculates a patient’s utility using the 3 measures when a user inputs their characteristics is provided at ,Our analyses found that models with multiple components fitted the data better than those with single components. This is consistent with findings from other disease areas, in which ALDVMMs with multiple components outperform linear regressions using ordinary least squares estimation.The inclusion of age and sex within components was both found to improve model fit. These variables are included in economic models as standard, and including them in utility estimation is important for accurately modeling utility over a long time horizon. Consistent with Brazier et al,Although visual acuity was a significant predictor within components and improved model fit for predicting component membership, it did not pick up a separate component for patients with utility at or below 0 for EQ-5D and EQ-5D V. This may be because of the presence of comorbidities within the population, which contributed to lower utility scores. Changing a person’s visual acuity alone would not change their underlying comorbidities and so would not change their probability of belonging to an additional component with different comorbidities. The LEAVO economic model did not specifically include comorbidities and instead implicitly assumed that patients have an average comorbidity profile, reflecting the likely data available to users of the mapping model and in line with good practice guidance.,In patients with CRVO, hypertension is a common comorbidity.A limitation of the robust estimator of the variance used in the statistical model was the inclusion of repeated observations of the same patients to increase the number of observations available. A cluster-robust estimator of the standard errors could have been used, which is robust in the presence of the correlation between observations for each individual. This does not change the estimated coefficients from the ALDVMM and affects only the standard errors used in the probabilistic sensitivity analyses.It is unclear whether our analyses could be applied in visual disorders other than macular edema secondary to CRVO. We note that some previous economic evaluations have assumed utilities are common across visual disorders, for example, the use of utilities from age-related macular degenerationOur mappings can be used to predict the EQ-5D, EQ-5D V, and VFQ-UI from BCVA. Our analyses found that including multiple components in ALDVMMs improved model fit. Our analyses can be used in economic evaluations to predict utility as a function of variables routinely included in economic models for visual disorders, but we note that other comorbidities may also contribute to absolute utility scores.